Discussion of interesting or befuddling cases related to pulmonary and critical care medicine.

Tuesday, August 16, 2005

Chest pain and abnormal CxR

This is a 52 year-old man. At approximately midnight prio to admission he was eating a piece of chicken on which he choked, gagged and strained and with heavy heaving, he suffered acute onset of abdominal pain and left chest pain. He presented urgently to the hospital and had the following studies.PMHx: HTN. No previous dysphagia/PUD. No label of pulmonary disease but he smoked 2 ppd. SHx: Occ ETOH, 2 PPD TOB.ROS: The time from the onset of symptoms to arrival in the ER was approximately 4.5 hours. He has had hematemesis since the onset of the event. He complains of generalized chest pain. No chronic or preceding weight loss or fever or chills, nausea or vomiting or diarrhea.On exam, he was restless, retching, blood pressure is 154/87, HR is 130. O2 Saturation is 94 to 95%. Chest had crackles and decreased BS at the base. Abdomen was surprisingly benign.What is your differential and what is the next step?

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The cxr is not big enough or high enough resolution to be sure, but it seems like there is mediastinal widening. Despite the lack of effusion, I would still be concerned for esophogeal perforation. Prior to endoscopy I would get an urgent chest CT, because he may need surgery. An EGD would not be recommended because it might worsen the perf. If he aspirated the bone into the lung, I can't see it on the plain film. The other thing I would do would be to sedate him a bit more to prevent further valsalva-induced worsening of the perf.

Yea, I can't make out much detail on the film. Regardless, the chest pain and tachycardia in this context is very concerning for Boerhave's (?spelling) and mediasteinitis. I guess that a chicken bone stuck in his esophagus could also cause spasm and hematemasis, with or without perforation. Nevertheless, I would start agressive volume resucitation and start broad-spectrum antibiotics while obtaining an emergent CT scan of the chest. Following those results, he should either go to surgery or endoscopy.